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HomeMy WebLinkAboutORANGE COUNTY SUPERINTENDENT OF SCHOOLS -20142 3 4 5 6 7 8 9 12 13 14 Is 16 17 18 19 20 21 22 23 24 25 INSURANUL M U14 MU WORK MAY M PROCEED CLERK OF COUNCIL DATE. -2,2 - 1 Robey-l- A-2014-017 Contract Number: 39898 SERVICE AGREEMENT FOR THE PROVISION OF GED TESTING SERVICES BETWEEN SANTA ANA POLICE DEPARTMENT AND ORANGE COUNTY SUPERINTENDENT OF SCHOOLS This AGREEMENT is hereby entered into this I" day of July, 2013, by and between the O`ra­ng­e­­County Superint7e—nlclent of Schools, 200 Kalmus Drive, Costa Mesa, California 92626, hereinafter referred to as SUPERINTENDENT, maintaining the Alternative, Charter and Correctional Schools and Services (ACCESS) Program, and the Santa Ana Police Department, 52 Civic Center Plaza, Santa Ana, California 92702, hereinafter referred to as DEPARTMENT. SUPERINTENDENT and DEPARTMENT shall be collectively referred to as the Parties. WHEREAS, DEPARTMENT is in need of GED Testing services on Saturdays to make testing more available to the community; and WHEREAS, SUPERINTENDENT is specially trained, experienced and (competent to conduct the GED Testing services; and WHEREAS, DEPARTMENT is agreeable to allowing SUPERINTENDENT to administer GED testing, hereinafter referred to as PROGRAM. NOW, THEREFORE, the Parties hereby agree as follows: 1.0 TERM. The term of this AGREEMENT shall commence on July 1, 2013, and end on June 30, 2016, unless sooner terminated by any of the parties in accordance with Sections 5.0 and 11,0 of this AGREEMENT. Page 1 I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 2.0 DUTIES AND RESPONSIBILITIES. A. SUPERINTENDENT agrees to: 1. Administer GED testing to examinees and public examinees identified by DEPARTMENT. 2. Provide GED testing materials, equipment and supplies necessary to administer the GED testing. 3. Administer at least one (1) GED testing session per month consisting of one (1) Saturday; duration of session not to exceed nine (9) hours. All examinees must be in the testing room for registration and testing will begin on time. GED Testing will take place at Santa Ana Police Department Jail Facility. 4. Provide yearly schedule of GED testing dates to DEPARTMENT. 5. Charge each examinee the following rates for the GED Testing: (a) Full Battery (English or Spanish) $125.00 Each Battery (5 subject tests, 1 Certificate L 1 official transcript) (b) Repeat any test $ 25.00 (c) Duplicate Certificate $ 20.00 (d) Extra Transcript $ 7.00 ea. (e) Score Challenge $ 14.00 ea. (f) Process Change of Information/ Address form $ 15.00 ea. Error fees: • Blank or incorrectly bubbled Demographic or answer form $20.00 per field • Ink Bubbles $20.00 per field • Retest submitted without Page 2 I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Pre - assigned ID# $20.00 per test 6. GED Examiners Fee Four hundred fifty ($450.00) dollars per two (2) day examination period in addition to the individual test fees charged; fees will be subject to change beginning January 1, 2014 due to GED program changes. 7. Inform DEPARTMENT and examinees of any increase in fees that are due to the California Department of Education, American Council on Education, or General Educational Testing Services of the rate adjustments. B. DEPARTMENT agrees to: 1. Provide a secure testing room with adequate space and testing stations, i.e., desks, tables, chalkboard, clock or other means of displaying written directions for SUPERINTENDENT to conduct GED testing prior to each scheduled testing. 2. Provide parking spaces close to the entrance of facility to insure safe transport of the GED testing materials. 3. Provide SUPERINTENDENT's staff assistance, when necessary, during testing to allow SUPERINTENDENT staff a break /emergency release time. 4. Provide easy and immediate access to DEPARTMENT staff member via intercom, telephone or other reliable means of communication. 5. Collect the GED testing fees from the examinees and transfer the funds to SUPERINTENDENT on a monthly basis. Page 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Payment shall be mailed to: Orange County Superintendent of Schools, 200 Kalmus Drive, Costa Mesa, California 92626, or at such other place as SUPERINTENDENT may designate in writing. 3.0 INDEPENDENT CONTRACTOR. SUPERINTENDENT is and at all times shall be deemed to be an independent contractor and shall be wholly responsible for the manner in which the services required by the terms of this AGREEMENT are performed. Nothing herein contained shall be construed as creating the relationship of employer and employee, or principal and agent, between the SUPERINTENDENT and DEPARTMENT'S or any of DEPARTMENT'S agents or employees. SUPERINTENDENT assumes the responsibility for the acts of its employees or agents as they relate to the services to be provided during the scope of their employment. SUPERINTENDENT, its agents, officers, and employees, shall not be entitled to any rights, and /or privileges of DEPARTMENT'S employees and shall not be considered in any manner to be DEPARTMENT'S employees. 4.0 PERSONNEL. SUPERINTENDENT and DEPARTMENT shall retain complete and absolute authority over their respective staff members assigned to the GED Testing Center. Neither party has the authority to discipline, suspend, or terminate from employment, or take action against the other parties staff members. 5.0 DUTY TO PROVIDE FIT WORKERS. SUPERINTENDENT and DEPARTMENT shall at all times enforce appropriate discipline and good order among their employees and shall not knowingly employ any unfit person or anyone not skilled in providing the services required under this Page 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 AGREEMENT. Any person in the employ of the SUPERINTENDENT or DEPARTMENT whom SUPERINTENDENT or DEPARTMENT deems incompetent, unfit, intemperate, troublesome or otherwise undesirable shall be excluded from providing services under this - AGREEMENT and shall not again provide services except with written consent of SUPERINTENDENT or DEPARTMENT. Collect the GED testing fees from the examinees and transfer the funds to SUPERINTENDENT on a monthly basis. 6.0 CONFIDENTIALITY. SUPERINTENDENT and DEPARTMENT shall maintain confidentiality of their respective records and information, concerning the examinees served pursuant to all applicable federal and /or state laws or regulations as each may now exist or be hereafter amended. 7.0 HOLD HARMLESS. A. DEPARTMENT agrees to and does hereby indemnify, hold harmless and defend the SUPERINTENDENT, the Orange County Board of Education and its officers, agents and employees from every claim or demand made and every liability, loss, damage or expense, of any nature whatsoever, which may be incurred by reason of: liability for damages for: (1) death or bodily injury to person; (2) injury to, loss or theft of property; or(3) any other loss, damage or expense arising out of (1) or (2) above, sustained by the DEPARTMENT or any person, firm or corporation employed by the DEPARTMENT, either directly or by independent contract, upon or in connection with the services called for in this AGREEMENT, however caused, except for liability for damages referred to above which result from the sole negligence or Page 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 willful misconduct of the SUPERINTENDENT, the Orange County Board of JEducation, or its officers, employees or agents. B. SUPERINTENDENT agrees to and does hereby indemnify, hold (harmless and defend DEPARTMENT, its officers, agents and employees from every claim or demand made and every liability, loss, damage or expense, of any nature whatsoever, which may be incurred by reason of: liability for damages for: (1) death or bodily injury to person; (2) injury to, loss or theft of property; or (3) any other loss, damage or expense arising out of (1) or (2) above, sustained by the SUPERINTENDENT or any person, firm or corporation employed by the SUPERINTENDENT, either directly or by independent contract, upon or in connection with the services called for in this AGREEMENT, however caused, except for liability for damages referred to above which result from the sole negligence or willful misconduct of DEPARTMENT, its officers, employees or agents. 8.0 EMERGENCIES. Any emergency situation affecting the welfare of minors including but not limited to riot, fire, flood and natural disaster shall be immediately communicated between the Parties. 9.0 RECORDS AND RETENTION. SUPERINTENDENT shall have access to books, documents, and records of DEPARTMENT pertinent to services performed in this AGREEMENT for auditing and evaluation purposes. DEPARTMENT shall have access to books, documents and records of SUPERINTENDENT pertinent to services performed in this AGREEMENT for purposes of audit and evaluation. Each of the parties shall maintain and preserve all books, financial statements, journals, ledgers, and other pertinent documents for a period of five (5) years from the Page 6 I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 termination of this AGREEMENT or for any period required thereafter by statute. 10.0 NON- DISCRIMINATION. DEPARTMENT and SUPERINTENDENT agree that they will not engage in unlawful discrimination in employment of persons because of race, color, religious creed, national origin, ancestry, physical handicap, medical condition, marital status, or sex of such persons. 11.0 TERMINATION. This AGREEMENT may be terminated by either party for cause upon notification to the other party in writing thirty (30) days in advance of the desired date of termination. 12.0 TOBACCO USE POLICY. In the interest of public health, SUPERINTENDENT provides a tobacco -free environment. Smoking or the use any tobacco products are prohibited in buildings and vehicles, and on any property owned, leased or contracted for by the SUPERINTENDENT pursuant to SUPERINTENDENT Policy 400.15. Failure to abide with conditions of this policy could result in the termination of this AGREEMENT. 13.0 NOTICE. All notices or demands to be given under this AGREEMENT by either party to the other, shall be in writing and given either by: (a) personal service or (b) by U.S. Mail, mailed either by registered or certified mail, return receipt requested, with postage prepaid. Service shall be considered given when received if personally served or if mailed on the third day after deposit in any U.S. Post Office. The address to which notices or demands may be given by either party may be changed by written notice given in accordance with the notice Page 7 1 2 3 M 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 provisions of this section. At the date of this AGREEMENT, the addresses of the parties are as follows: DEPARTMENT: Santa Ana Police Department 52 Civic Center Plaza Santa Ana, California 92702 Attn: Donna Estrada SUPERINTENDENT: Orange County Superintendent of Schools 200 Kalmus Drive P.O. Box 9050 Costa Mesa, California 92628 -9050 Attn: Patricia McCaughey 14.0 MISCELLANEOUS A. The failure of SUPERINTENDENT or DEPARTMENT to seek redress for violation of, or to insist upon, the strict performance of any term or condition of this AGREEMENT, shall not be deemed a waiver by that party of such term or condition, or prevent a subsequent similar act from again constituting a violation of such term or condition. B. This AGREEMENT and any exhibits attached hereto constitute the entire agreement among the Parties to it and supersedes any prior or contemporaneous understanding or agreement with respect to the services contemplated, and may be amended only by a written amendment executed by both Parties to the AGREEMENT. Page 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 IN WITNESS WHEREOF, the Parties hereto have caused this AGREEMENT to be executed. SANTA ANA POLICE DEPART ENT BY: C"mk Authorized Signature PRINT NAME: qr/"CV$ KQJ. q_� TITLE: jpQCI C C / /�y ''�'� /��° DATE: t 1! /' l9< ` -- Santa Ana Police Dept.- GED- Income(39898)16 ZIP6 APPROVED VED AS TO FORM Laura A. Rossini Assistant City Attorney ORANGE C TY SUPERINTENDENT OF SCH00 d � BY: 1 / ' 41/ Authorized PRINT NAME: Patrici TITLE: Coordinator DATE: October 8, 2 Page 9 ATTEST: MARIA HUIZAR Clerk of the Council CITY OF SANTA ANA <- 4 DAVID CAVAZOS City Manager � : A -,0( /y -G`7 CRANU COMP` I DrUAR'NiftT Of EDUCATION ... , ..j'� lid, �'�� �.R!.•L kr< casttg Es9cA^ClStvt ut °atha�a OR?t�zE 1iY ! BOAM Of EMAiift4 3I H V..Ij L' March 5, 2014 City of Santa Ana 60 Civic Center Plaza Santa Ana, CA. 92702 Re: Verification of Workers' Compensation Coverage To Whom It May Concern: The Orange County Superintendent of Schools is self - insured for its Workers' Compensation coverage through the Western Orange County Self - Funded Workers' Compensation Agency, a Joint Powers Authority (JPA). We are self - insured up to $500,000. Our self - insured certificate number is A -5532- 10 -132. Employees are provided statutory workers' compensation benefits. If you are in need of further details or have any questions, please feel free to contact me at (714) 966 -4059. Sincerely, ppROV'EId AS TO FF,O_Re Kantornator Laura A. Rossini Risk Management Assistant City Attorney 2: 13 ".y k Arch IL Insurance Group ARCH INSURANCE COMPANY (A Missouri Corporation) Home Office Address: 3100 Broadway, Suite 511 Kansas City, MO 64111 Administrative Address: One Liberty Plaza, 53rd Floor New York, NY 10006 Tel: (800) 817 -3252 SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY DECLARATIONS Policy Number: WCX 0055277 00 Item 1: Named Insured: Western Orange County Self- Funded Workers' Compe Address: 200 Kalmus Drive, Room 1117, Costa Mesa California 92626 Producer Name: Swett & Crawford of Woodland Hills Address: 21650 Oxnard Street, Suite 1400, Woodland Hills California 91367 -4901 I Item 2: Policy Period: I Inception Date: I July 1, 2013 1 Expiration Date: I July 1, 2014 1 Time at your mailing address as Item 3: This insurance applies to the Workers Compensation and Occupational Disease Laws of the following states: California Item 4: Premiums Estimated Total Annual Remuneration: $ 218,245,927 Rate per $100 of Remuneration: .1480 Deposit Premium: $ 323,004 (Terrorism Premium Included In Policy Premium ): $ 9,690 Minimum Premium: $ 306,654 Item 5: Your Retained Limit PPRBVED AS T,0 FORK:, CttIvrk 0 t Laura A. Rossini Assistant City Attorney Part One - Excess Workers Compensation Insurance and Part Two- Excess Employers Liability Insurance: Your Retained Limit of Liability - Each Accident $500,000 Your Retained Limit of Liability - Disease, Each Employee $500,000 05 GL0400 00 (01 08) Page 1 of 2 Item B: Our Limit of Liability A. Part One — Excess Workers Compensation Insurance: Our Limit of Liability — Each Accident Statutory Our Limit of Liability — Disease, Each Employee Statutory B. Part Two — Excess Employers Liability Insurance: Our Limit of Liability - Each Accident $ 1,000,000 Our Limit of Liability - Disease, Each Employee $ 1,000,000 Our Limit of Liability - Aggregate $ 1,000,000 Policy Forms and Endorsements: See Schedule of Endorsements Forming a Part of this Policy Authorized Representative: Date: July 8, 2013 05 GL0400 00 (01 08) Page 2 of 2 SCHEDULE OF FORMS AND ENDORSEMENTS NAMED INSURED: Western Orange County Self- Funded Workers TERM: July 1, 2013 to July 1, 2014 Compensation Agency POLICY NUMBER: WCX 0055277 00 00 ML0012 00 01 03 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LOSSES REDEFINED TO INCLUDE ALLOCATED LOSS ADJUSTMENT EXPENSES ENDORSEMENT This endorsement modifies insurance provided under the following: SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PART FIVE — DEFINITIONS, E. "Loss(es)" is deleted in its entirety and replaced by the following: E. "Loss(es)" means any payments for benefits required to be paid by you under the "Workers Compensation Law" or any payments for damages arising out of "bodily injury by accident" or "bodily injury by disease" covered either by PART ONE or PART TWO of this policy. "Loss(es)" include "allocated loss adjustment expenses". 2. PART SEVEN — ALLOCATED LOSS ADJUSTMENT EXPENSES is deleted in its entirety. All other terms and conditions of this policy remain unchanged. Endorsement Number: 1 Policy Number: WCX 0055277 00 Named Insured: Western Oranae County Self- Funded Workers' Compensation Agency This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: July 1. 2013 00 GL0386 00 (01 08) Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA VOLUNTEER COVERAGE - EXCESS VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement modifies insurance provided under the following: SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY A. How This Insurance Applies This insurance applies, with respect to this endorsement, to "bodily injury by accident" or "bodily injury by disease" provided that the: 1. "Bodily injury" must be sustained by a person included in the group of volunteers described in the Schedule; 2. "Bodily injury" must arise out of and in the course of volunteer activities necessary or incidental to your operations in a "state" listed Schedule below; 3. "Bodily injury' must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places; and 4. "Bodily injury by accident" must occur during the "policy period ". 5. "Bodily injury by disease' must be caused or aggravated by the conditions of your operations. The volunteer's last day of last exposure to the conditions causing or aggravating such "bodily injury by disease" must occur during the "policy period ". SCHEDULE Volunteers Designated Workers Compensation Law All volunteers who donate their services to you and are not subject to Workers Compensation Law or Occupational Disease Law Workers Compensation Law and Occupational Disease Law of the "state" where the injury takes place. B. We Will Reimburse We will reimburse you for the amount equal to the benefits that is excess of Your Retained Limit stated in Item 5 of the Declarations Page that would be required of you if you and your volunteer(s) described in the Schedule above were subject to the "Workers Compensation Law" shown in the Schedule. This reimbursement by us will not exceed Our Limit of Liability as stated in Item 6 A. of the Declarations Page. Endorsement Number: 2 Policy Number: WCX 0055277 00 Named Insured: Western Orange County Self- Funded Workers' Compensation Agency This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: July 1. 2013 00 GL0368 05 (01 08) Page 1 of 2 CALIFORNIA VOLUNTEER COVERAGE - EXCESS VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT C. Exclusions - Payments You Must Make This insurance does not cover, nor is Your Retained Limit satisfied by, any of the following types of payments. 1. Any obligation imposed by a workers compensation or occupational disease law, unemployment compensation, or disability benefits law or any similar law; 2. "Bodily injury" intentionally caused or aggravated by you; or 3. Liability for any consequence, whether direct or indirect, of war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, insurrection, rebellion, revolution, or military or usurped power. No endorsement now or subsequently attached to this policy will be construed as overriding or waiving this limitation unless specifically referenced. D. Our Reimbursement Before we will reimburse you for the amount equal to the benefits that is excess of Your Retained Limit, the claimants must: 1. Transfer to us the claimant's right to recover from others who may be responsible for the injury or death; and 2. Cooperate with us and do everything necessary to enable us to enforce the right of recovery from others. If the claimants make a recovery from others, the claimant must reimburse us for any benefits we have reimbursed you. If the persons entitled to the benefits fail to do these things, our duty to reimburse ends at once. If they claim damages from us for the injury or death, our duty to reimburse ends at once. E. Employers Liability Insurance PART TWO - EXCESS EMPLOYERS LIABILITY INSURANCE applies to "bodily injury' covered by this endorsement as though the "state(s)" shown in the Schedule were listed in the Item 3 of the Declarations Page subject to Your Retained Limit indicated in Item 5 of the Declarations Page. Our reimbursement will not be more than Our Limit of Liability stated in Item 6 B. of the Declarations Page. All other terms and conditions of this Policy remain unchanged. Endorsement Number: 2 Policy Number: WCX 0055277 00 Named Insured: Western Orange County Self- Funded Workers' Compensation Agency This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: July 1, 2013 00 GL0368 05 (01 08) Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. C. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applicable Program Year. "Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable. Endorsement Number: 3 Policy Number: WCX 0055277 00 Named Insured: Western Oranoe County Self- Funded Workers' Compensation Agency This endorsement is effective on the inception date of this policy unless otherwise stated herein. Endorsement Effective Date: July 1. 2013 00 GL0253 00 (01 08) Page 1 of 2 Includes copyright material of the National Council on Compensation Insurance, Inc. with its permission. 0 2007 National Council on Compensation Insurance, Inc. TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT ENDORSEMENT Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a Program Year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceeds $100,000,000 in a Program Year, the United States Government would pay 85% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceeds $100,000,000,000. 3. The additional premium charged for the coverage for Insured Losses under the policy is included in the deposit premium listed in Item 4 of the Declarations Page and is itemized in the Schedule below. State Califomia SCHEDULE Rate per $100 of Remuneration .0044 All other terms and conditions of this Policy remain unchanged. Endorsement Number: 3 Policy Number: WCX 0055277 00 Named Insured: Western Orange County Self- Funded Workers' Compensation Agencv This endorsement is effective on the inception date of this policy unless otherwise stated herein. Endorsement Effective Date: July 1. 2013 00 GL0253 00 (01 08) Page 2 of 2 Includes copyright material of the National Council on Compensation Insurance, Inc. with its permission. © 2007 National Council on Compensation Insurance, Inc. THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. CALIFORNIA AMENDATORY ENDORSEMENT This endorsement modifies insurance provided under the following: SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY I. PART FOUR • VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE, D. Our Reimbursement is deleted in its entirety and replaced with the following: D. Our Reimbursement Before we will reimburse you for the amount equal to the benefits that is excess of Your Retained Limit, the claimants must: 1. Transfer to us the claimant's right to recover from others who may be responsible for the injury or death; and 2. Cooperate with us and do everything necessary to enable us to enforce the right of recovery from others. If the persons entitled to the benefits fail to do these things, our duty to reimburse ends at once. If they claim damages from us for the injury or death, our duty to reimburse ends at once. II. PART NINE — CONDITIONS, Condition K. Cancellation or Non - renewal is deleted in its entirety and replaced with the following: K. Cancellation 1. You may cancel this policy. You must mail or deliver advance notice to us stating when the cancellation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non - payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of the policy or of a previous policy issued by us; d. to pay any additional premium as a result of a audit of payroll as required by the terms of the policy or of a previous policy issued by us e. Material misrepresentation made by you or your agent; Endorsement Number: 4 Policy Number: WCX 0055277 00 Named Insured: Western Orange County Self- Funded Workers' Compensation Agencv This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: July 1. 2013 00 GL0403 05 (01 08) Page 1 of 2 CALIFORNIA AMENDATORY ENDORSEMENT f. Failure to cooperate with us in the investigation of a claim; g. Failure to comply with federal or state safety orders; h. Failure to comply with written recommendations of the insurers designated loss control representative; i. The occurrence of a material change in ownership or any change in your business; j. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; k. The occurrence of any change in your business or operations that requires additional or different classifications for premium calculations; or I. The occurrence of any change in your business or operations which contemplates an activity excluded by our reinsurance treaties. If we cancel for any reason listed in (a) through (f), we will give you ten (10) days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information page will be sufficient to prove notice. If we cancel for any reason listed in (g) through (1), we will give you thirty (30) days advance written notice; however, we agree that in the event cancellation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 3. In addition, if we cancel this policy, we will deliver thirty (30) days advance written notice to: Office of Self- Insurance Plans 2265 Watt Ave., Suite 1 Sacramento, CA 95825 4. The "policy period" will end on the day and hour stated in the cancellation notice. All other terms and conditions of this policy remain unchanged. Endorsement Number: 4 Policy Number: WCX 0055277 00 Named Insured: Western Orange County Self- Funded Workers' Compensation Aaencv This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: July 1 2013 00 GL0403 05 (01 08) Page 2 of 2